1. The programme at a glance
Indication. Adults with active suicidal thoughts, who have made a recent suicide attempt, or who have repeated suicidal behaviour, seen as outpatients once immediate safety has been established. The programme applies whatever the associated disorder — depression, bipolar disorder, personality disorder, alcohol use disorder, post-traumatic stress disorder — and also when no established disorder is present.
Reference model. A cognitive behavioural therapy focused on suicidal behaviour itself, built on the cognitive therapy for suicide prevention described by Wenzel, Brown and Beck, on Stanley and Brown's safety planning intervention, and on the collaborative stance that Jobes proposes for engaging the person in care; these approaches are presented in section 18. It borrows chain analysis (section 36) and regulation skills from dialectical behaviour therapy (section 40), and it builds in proactive caring contacts after an attempt (section 41).
Format. Twelve individual 50-minute sessions; sessions 1, 2 and 11 benefit from lasting 75 minutes. Two sessions in the first week, then one a week. One session is shared with someone close to the person, chosen by them. Two booster sessions, at one month and at three months, and a brief written contact in between.
Mechanism targeted. Not to eliminate every thought of death, but three changes: making the next crisis possible to get through without acting, by preparing for it in advance, while calm; reducing what makes life unbearable — hopelessness, problems with no apparent way out, isolation, overwhelming emotions; and enabling the person to recognise the crisis early and to ask for help before it closes in on them.
| Session |
Focus |
Session output |
| 1 |
Welcome, assess, make safe |
Initial formulation, minimal plan, dated next steps |
| 2 |
The crisis narrative |
Sequence of the crisis written down |
| 3 |
The safety plan |
Plan written in the person's own hand |
| 4 |
Understanding the crisis |
Shared formulation, two or three targets |
| 5 |
Reasons for living |
Written list, crisis card |
| 6 |
Hopelessness, and the mid-point review |
One thought put to the test, review in figures |
| 7 |
One problem at a time |
One problem broken down, one dated action |
| 8 |
Getting through the wave |
Two skills tried in session |
| 9 |
Connection and burden |
One sentence prepared, one contact scheduled |
| 10 |
Session with someone close |
Shared plan, role of the close person written down |
| 11 |
Guided revisiting of the crisis |
Exercise done, plan corrected |
| 12 |
Review, relapse, handover |
Plan for what comes next, booster sessions dated |
What the person takes away. Ten printable worksheets, listed in section 51: my record, the story of my crisis, my safety plan, my reasons for living, my crisis card, when everything closes in, one problem at a time, getting through the wave, the corner for those close to you, my plan for what comes next.
What distinguishes this programme from the other manuals on this site. Three things. Suicidal behaviour is the target, and not a symptom that is expected to disappear along with the associated disorder. Assessment is a formulation, and the manual says frankly what scales cannot do. And connection is part of the treatment: the early follow-up appointment, the call after a missed appointment, caring contacts and the preparation of transitions are described with the same precision as the sessions.
2. Before you begin
The four preliminary decisions
Is there an emergency today? Active intent, a plan, access to means, completed preparations, an attempt in the preceding hours, current alcohol or substance use. Section 15 gives the criteria, which are weighed together. If an emergency is evident, the session changes its purpose and referral is organised now.
Can the person be followed as an outpatient? The answer depends less on the severity of the last act than on three things: their ability to engage with a safety plan, the possibility of reducing access to means, and the possibility of maintaining contact between sessions.
What is going on underneath? Depression, bipolar disorder, psychotic disorder, alcohol, personality disorder, trauma, pain or physical illness. Sections 8 and 9 give the differential diagnosis and the comorbidities. The programme does not exempt you from treating them; it is added to that treatment.
Who else is part of the care arrangement? The GP, a psychiatrist, the team that saw the person in the emergency department, a recontact service, someone close. Treatment for suicidal behaviour is not carried out behind a closed consulting-room door, and the question is settled at the first session.
What this programme does not treat
It does not treat a crisis in progress. A person who has active intent and means available needs immediate referral, not a first appointment in a fortnight.
It does not, on its own, treat an acute psychotic episode, a manic or mixed episode, withdrawal, or severe undernutrition. The specialist opinion comes first; the programme can be added afterwards.
It does not apply as it stands to adolescents. The legal framework, the place of parents and the clinical presentations differ: see Suicidal behaviour and self-harm in adolescents: a therapist's manual.
It does not treat a situation of ongoing violence. When the person lives with someone who puts them in danger, protection comes first, and it calls for specialist referral, to victim support services.
It does not replace institutional care when that is indicated: crisis unit, day hospital, hospital admission. Section 15 says when to consider it.
How to use it
Read the whole text before the first session, in particular sections 11, 12, 14, 15, 16 and 35: assessment as formulation, the interview about suicidal thoughts, restricting access to means, the acute crisis, professional confidentiality, and the safety plan. These are the six places where people go wrong, and five of them can have consequences within the day.
Each session is described using the same framework: the aim, the steps, what you say, common mistakes, and the criterion for moving on.
Three warnings specific to this reason for referral.
You will be afraid. That is normal, and it is not a failing in your training. What matters is that fear does not make the decisions for you: not reflex hospital admission, not avoiding the subject after the third session, not the extracted promise.
Zero risk does not exist, and this manual does not promise it. Some of the people you see will make another attempt, and some will die, including when everything has been done correctly. What is offered here reduces repetition and makes the work sustainable. Section 50 is for you.
And you are not working alone. Before the first session, know whom you call for an opinion, at what time, and where you refer someone at 6.50 pm on a weekday evening.
3. Five situations not to be confused
Under the word "suicidal" come five situations that call for neither the same urgency, nor the same pace, nor the same course of action. They often overlap, and that is precisely why they need to be told apart.
1. Passive thoughts of death
What you observe. "I wish I wouldn't wake up." "If I disappeared, it wouldn't matter." A wish no longer to be here, with no intention of acting and no plan. It is common in depression, grief, serious illness and exhaustion.
What points the way. The absence of intent, the absence of a plan, and relative stability over time.
What this implies. You ask, you document, you treat what lies underneath, and you ask again. A simple safety plan is often useful. But the boundary with active thoughts is less clear-cut than people think, and it is sometimes crossed within a few days: the question has to be asked again.
2. The acute suicidal crisis
What you observe. Active, intrusive thoughts, often recent, rising intent, a sense of being at a dead end, agitation, insomnia, and sometimes preparations.
What points the way. The rapid trajectory, the intent, the feeling of being trapped, and the disappearance of what was holding the person back.
What this implies. See section 15. Safety comes before everything else, and the programme begins once immediate safety has been established.
3. After an attempt
What you observe. A recent attempt, whether or not it was seen in the emergency department. An intent that is often ambivalent, sometimes reconstructed after the event; relief at having survived, or, on the contrary, regret.
What points the way. A previous attempt is one of the factors most consistently associated with a further attempt and with death by suicide, and the weeks and months that follow are a period of high risk.
What this implies. A first appointment within the following days, organised caring contacts, and the whole programme. The narrative in session 2 is central here.
4. Chronic suicidal thoughts
What you observe. Thoughts present for years, sometimes almost daily, often in a context of borderline personality disorder, early trauma or chronic depression. They sometimes have a soothing function: "knowing that I could is what allows me to keep going".
What points the way. How long they have been there, their stability, and that function. But an acute crisis can be superimposed on this background, and that is what has to be picked up.
What this implies. You do not treat every day as an emergency: that exhausts everyone and makes the alarm unusable on the day it matters. You look for what is changing compared with the usual background. See section 43, and section 40 for dialectical behaviour therapy, often the most suitable framework.
5. Non-suicidal self-injury
What you observe. Self-inflicted acts carried out with no intention of dying, which most often serve to bring down tension, to get out of a state of emptiness or to punish oneself.
What points the way. The intent, the function, and the rapid relief that follows.
What this implies. See section 42. And two sentences that go together: it is not a suicide attempt, and yet it is associated with an increased later risk of suicide. The two behaviours often coexist in the same person.
The four triage questions
"What were you hoping would happen?" It is better than "did you want to die?", which invites a defensive answer. The answers are often clear: for it to stop, to sleep, to disappear, for the tension to come down, to die.
"Since when have you been thinking about it in this way?" It gives the trajectory, which counts for more than the day's intensity.
"What has changed in the last few days?" In a person who has been thinking about it for a long time, this is the question that picks up the acute crisis.
"What did you do just afterwards?" Call someone, hide, wait, nothing. Behaviour afterwards says more about intent than the account of the intent does.
What the medical severity of the act does not tell you
It does not tell you the intent. An act of low medical severity can accompany a strong intention to die, and the reverse also happens. Intent and medical severity are two distinct dimensions: they are assessed separately.
It does not tell you the prognosis. Repetition and context count for more.
And it does not tell you the suffering. This is the most hurtful mistake, and it is still made in emergency departments.
4. The dimensions to distinguish
Vocabulary matters, because a record that says "suicidal thoughts" without further detail says almost nothing. Here are the distinctions that are useful, and that structured interview tools (section 13) use in similar forms.
Thoughts of death. Thinking about death, wishing no longer to be here, without any thought of taking one's own life.
Suicidal thoughts. Thinking about taking one's own life. They are described by their frequency, their duration, their intensity, whether they can be pushed away, and what holds the person back.
Intent. The extent to which the person means to act. It may be absent, ambivalent, fluctuating or firm, and it is asked about in its own right, because the thoughts do not reveal it.
The plan. The degree of elaboration: a time, a place, a means considered. You need to know whether a means is being considered and whether it is accessible, because that is what determines restriction of access. You need nothing more.
Preparations. Acts that prepare for a suicidal act without being one: arrangements, farewell messages, putting affairs in order, giving away belongings, searches linked to a plan.
The interrupted attempt and the aborted attempt. A suicidal act begun and then stopped — by someone or something external in the first case, by the person themselves in the second. They are rarely mentioned spontaneously, and they count as history.
The suicide attempt. A self-inflicted act carried out with at least a partial intention to die.
Non-suicidal self-injury. A self-inflicted act without any intention to die.
A note on reading. In British usage, and therefore in the texts of NICE (the National Institute for Health and Care Excellence, the British body that publishes clinical practice guidelines; section 11), the word "self-harm" refers to any self-inflicted act, whatever the intent. The two categories above are combined there, and you need to know this to read those texts.
The forgotten dimension: time
Thoughts fluctuate within a few hours. Studies that measure them several times a day show, in almost all the people followed, large variations from one measurement to the next, a few hours apart (Kleiman et al., 2017). An assessment made at 10 am says little about 11 pm. This is the main reason why the safety plan counts for more than the note in the record.
The interval between the decision and the act can be very short. In a study of people interviewed within three days of an attempt, nearly half placed the interval between the first suicidal thought of the episode and the act at ten minutes or less (Deisenhammer et al., 2009). This is what underpins restricting access to means: putting time and distance between the impulse and the act.
What to ask about each dimension
Frequency, duration, intensity, controllability, what holds the person back, and the trajectory over recent weeks. And three points in time: the last forty-eight hours, the last two weeks, and the worst moment in the person's life.
5. What makes the crisis possible, and what makes it pass
Three useful models
The interpersonal theory (Van Orden et al., 2010). The desire to die is thought to arise from the combination of two states: the feeling of being a burden on others, and the feeling of no longer belonging to anything or anyone. Acting would additionally require an acquired capability, through gradual habituation to pain and to the fear of death. What this changes in practice. The feeling of being a burden is looked for explicitly: it is rarely voiced unprompted, and it is often at the heart of the crisis.
The integrated motivational-volitional model (O'Connor and Kirtley, 2018). An experience of defeat or humiliation produces a feeling of entrapment; when no way out appears, suicidal thoughts emerge. The move from thought to act then depends on so-called volitional factors: access to means, exposure to the suicidal behaviour of others, capability (lack of fear of death, increased tolerance of physical pain), planning, impulsivity, mental imagery, and past behaviour. What this changes in practice. The feeling of entrapment is a target. And the model places mental imagery, including imagery of one's own death, among the factors that lead to acting: this is why, in this programme, no imaginal exercise ever focuses on the act itself.
The three-step theory (Klonsky and May, 2015). Thoughts arise from pain combined with hopelessness; they become strong when the pain outweighs connection with others and with what matters; acting depends on a capability, part of which is practical — access, knowledge. What this changes in practice. Connection is a therapeutic lever, not a backdrop. And practical capability is the most modifiable part of the picture.
What they have in common
All three distinguish what gives rise to the thoughts from what leads from thought to act. This is the most useful distinction in this section, because the great majority of people who have suicidal thoughts never act on them, and the two are not worked on with the same tools.
On the side of the thoughts: psychological pain, hopelessness, the feeling of entrapment, the feeling of being a burden, isolation. Targets of sessions 5 to 9.
On the side of acting: access to means, alcohol, impulsivity, agitation, insomnia, exposure to other people's suicidal behaviour. Targets of sessions 1 to 3 and 8, and of section 14.
The crisis is brief, and that is good news
The most acute phase of a suicidal crisis most often lasts hours or days, not months. Ambivalence is the rule: part of the person wants to die, another part wants the pain to stop, and these are not the same thing. And the great majority of people who have self-harmed, attempts included, do not go on to die by suicide — even though their risk remains far higher than that of the general population, for years (Owens et al., 2002).
The whole programme rests on this fact: if the crisis is got through, there is an afterwards, and it can be prepared for.
What keeps the crisis going
Hopelessness. It is more closely linked to acting than sadness is. The conviction that nothing will change is the most important cognitive target of the programme.
Attentional fixation. In the crisis, attention narrows onto death as the only way out, and the other possibilities become literally invisible (Wenzel et al., 2009). That is why they must be written down in advance.
The sense of the unbearable. "I can't go on." It does not say that a situation is impossible; it says that it exceeds what the person thinks they can bear, now.
Withdrawal. It protects against shame and deprives the person of what would help.
Alcohol and insomnia. They lower the threshold, shorten the interval, and render everything else ineffective.
And, in some people, the thought itself. When thinking about suicide brings relief — "it's a way out" —, the thought is reinforced by the relief it gives. This is common in chronic suicidal thoughts, and it is treated as a behaviour, not as an opinion.
Frequently asked questions
Can talking about suicide give someone the idea?
No. This has been studied and the answer is consistent: asking the question does not induce suicidal thoughts, and may even reduce them. What is dangerous is not asking.
Should a risk scale be used?
To describe and to monitor, yes, if it helps you document in a comparable way. To predict or to decide on access to care, no: none is capable of it, and the 2022 British guidelines explicitly advise against it. See section 11.
The person denies any suicidal thoughts, but I am still worried.
Note what worries you — hopelessness, withdrawal, farewells, alcohol —, say so, and act on what you observe: safety plan, access to means, an early appointment, with their agreement someone close. Denial is not a reassuring answer.
Should the person sign a commitment not to act?
No. The no-suicide contract has not proved itself, and it can prevent the person from saying that things are going badly. A safety plan is written instead.
Should every attempt lead to hospital admission?
No. The decision rests on the criteria in section 15 and on what can be organised on an outpatient basis. What is non-negotiable is an appointment within the following days, a written plan, and reduced access to means.
How far should you ask for detail about the means?
As far as knowing what was considered or used and whether it is accessible, in order to organise restriction of access and the medical assessment. No further: the detail adds nothing clinically and can strengthen the imagery that makes acting easier.
The person has had suicidal thoughts for years. Should you react every time?
No. You look for what is changing compared with the usual background — intent, plan, preparations, loss, alcohol — and you react to that change. Treating every day as an emergency exhausts everyone and makes the alarm unusable. See section 43.
She made another attempt during treatment. Has the treatment failed?
It is not a verdict: it is information, and it is the material for the next session. You go back over the sequence, correct the plan, check access to means, review the formulation — and ask yourself, with section 46, whether the format is sufficient.
Should I inform the family against the person's wishes?
In case of serious and immediate danger, yes, according to the rule announced at the first session and the legal framework of your country. Outside that situation, you seek agreement, and you can always listen to someone close without passing anything on to them. See section 16.
Is medication enough?
No. No medication treats suicidal behaviour as such. Medication treats the associated disorder, and some drugs have specific data on risk in particular indications. See section 19.
What if the person does not come back?
Call the same day, then the named person if you are worried, and write. In this indication, a missed appointment is a signal that calls for action.
How long before things get better?
Use of the plan and the ability to get through a crisis often shift within a few weeks. Hopelessness shifts more slowly, and the thoughts more slowly still; residual thoughts at the end of treatment are common. Saying so in advance avoids concluding that it has failed when the essential has changed.
And if a patient dies by suicide?
Do not stay alone, do not touch the record, follow your organisation's procedures, and look after yourself. Section 50 is written for that day.